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Differential Survival of Penetrating and Lamellar Transplants in Management of Failed Corneal Grafts

Educational Objective
To examine the corneal transplant replacement survival rates for the 3 main indications and types of regraft surgery.
1 Credit CME
Key Points

Question  Is actuarial survival of replacement corneal transplants associated with primary corneal diagnosis and type of regraft donor (lamellar or penetrating)?

Findings  In a national transplant registry study in the United Kingdom of 9925 regrafts, the proportion of endothelial keratoplasty regrafts increased to 38.0% in the most recent year of analysis, and stratification of 5-year survival was found for successive grafts in the same eye. For first regrafts in keratoconus and pseudophakic bullous keratopathy but not Fuchs dystrophy, no differences in survival after lamellar and penetrating keratoplasty procedures were identified.

Meaning  Survival of replacement grafts had greater association with the number of prior grafts than primary corneal diagnosis or type of regraft procedure (penetrating or lamellar).

Abstract

Importance  An increasing proportion of corneal transplant procedures are undertaken for replacement of a failed previous graft. The proportion of lamellar transplant procedures has significantly increased. There are limited large-scale reports on regraft procedures that may help guide surgeons and patients in their choice of surgery.

Objective  To examine the corneal transplant replacement survival rates for the 3 main indications and types of regraft surgery.

Design, Setting, and Participants  This national transplant registry study examined surgery and follow-up data on all corneal transplants performed in the United Kingdom from April 1, 1999, through March 31, 2016.

Main Outcomes and Measures  Actuarial regraft 5-year survival rates were compared for the 3 main indications and types of graft: penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty for keratoconus, PK and endothelial keratoplasty (EK) for Fuchs endothelial dystrophy (FED), and pseudophakic bullous keratopathy (PBK).

Results  A total of 9925 regrafts were analyzed during the 17-year study period. Penetrating keratoplasty represented 7261 cases (73.2%) in the cohort. Endothelial keratoplasty increased by 1361.5%, from 12 (2.6%; 95% CI, 1.3%-4.5%) of all 467 regrafts during 2005-2006 to 292 (38.0%; 95% CI, 34.6%-41.6%) of 768 during 2015-2016. The median time to first regraft for all graft types was 28 months (interquartile range, 10-64 months). When examining all graft types performed for all indications, stratification of 5-year survival was found for successive grafts, with a difference in survival of 25 270 (72.5%; 95% CI, 71.7%-73.2%) from the first graft to 4224 (53.4%; 95% CI, 51.4%-55.4%) from the second graft and 1088 (37.3%; 95% CI, 33.4%-41.3%) from the second to third graft. For first regrafts in keratoconus and PBK, survival after lamellar and PK procedures was similar. For FED, there was a higher regraft survival after PK (375 [70.8%]; 95% CI, 64.6%-76.1%) compared with EK (303 [54.7%]; 95% CI, 45.8%-62.8%) (P < .001). For FED and PBK, there was no difference in first regraft survival identified between EK followed by PK vs PK followed by PK or EK followed by EK vs PK followed by EK.

Conclusions and Relevance  In this large registry-based analysis of corneal regraft survival, regraft survival was found to vary with indication for first graft surgery and for FED with type of regraft procedure performed. For FED and PBK, the permutation of graft and subsequent first regraft procedure were not associated with any survival benefit for the first regraft. These reported outcomes may assist decision-making in management of a failed corneal transplant.

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Article Information

Accepted for Publication: March 24, 2018.

Corresponding Author: Daniel F. P. Larkin, MD, FRCOphth, Moorfields Eye Hospital 162 City Rd, London EC1V 2PD, England (f.larkin@ucl.ac.uk).

Published Online: June 21, 2018. doi:10.1001/jamaophthalmol.2018.1515

Author Contributions: Drs Jones and Larkin had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Aboshiha, Jones, Larkin.

Acquisition, analysis, or interpretation of data: Aboshiha, Jones, Hopkinson, Larkin.

Drafting of the manuscript: Aboshiha, Larkin.

Critical revision of the manuscript for important intellectual content: Aboshiha, Larkin.

Statistical analysis: Aboshiha, Jones, Hopkinson.

Study supervision: Aboshiha, Larkin.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This research was supported in part by the National Institute for Health Research Moorfields Biomedical Research Centre and the National Institute for Health Research Moorfields Clinical Research Facility, London, England.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Disclaimer: The views expressed are those of the authors and not necessarily those of the National Institute for Health Research.

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